J. Michael Henderson, M.D.
Chief Quality Officer
March 24, 2010
VIA UPS OVERNIGHT
Ms. Marilyn Samuels
Principal Program Representative
Non-Long Term Certiication & Enforcement Branch
Division of Survey and Certiication
Centers for Medicare & Medicaid Services, Region V
233 North Michigan Avenue, Suite 600
Cleveland Clinic (CCN 36-0180)
Dear Ms. Samuels:
On behalf of Cleveland Clinic Hospital (the "Hospital"), we submit the enclosed Plan of Correction
(the "POC") prepared by the Hospital in response to a Form 2567 Statement of Deiciencies received
from your ofice in relation to a complaint survey completed January 21, 2010.
The Hospital appreciates the opportunity to provide further information and background in relation to
the findings under Tag A123, as well as providing the POC for all cited tags. If there are any
questions regarding that information, the POC components of the document or the attachments, please
call Sandra DiVarco at 312-984-2006. Ms. DiVarco is an attorney specializing in regulatory matters
who is assisting the Hospital with the implementation of the POC.
The Hospital is eager to resolve these issues with CMS. If you have any questions, or if we can
provide you with additional information regarding the enclosed Plan of Correction and its
attachments, please contact me via phone at 216-444-8462 or via e-mail at email@example.com, or
Ms. DiVarco at the number provided above.
J. Michael Henderson, M.D.
Chief Quality Oficer
cc: Mr. Roy Croy, Bureau Chief, Division of Quality Compliance, Ohio Department of Health
Ms. LaTonya Mars, Senior Account Representative, The Joint Commission
The Cleveland Clinic Foundation
9500 Euclid Avenue
Quality & Patient Safety Institute
RII 12 Grievance Policy
Page 2 of 3
• Injury sustained during service
• Confidentiality problem
• Requests to speak to someone in administration
• Concern regarding an area other than their own
• Complex medical care issues
• An inability to resolve the issue as point of service
• Any complaint regarding the care provided to the patient
• An allegation of abuse or neglect, or
• Failure to support "Patient Rights" as outlined by CMS guidelines
All written complaints from a patient or a patient's legal representative constitute a grievance and
should be forwarded to the Ombudsman Office immediately via fax at 216-445-6086, scanned
email to firstname.lastname@example.org, or delivery to Mail Code, S18.
Any concen regarding the patient's care, abuse or neglect, issues related to the hospital's
compliance with the CMS Conditions of Participation or beneficiary complaints requires
investigation and resolution to the complainant. Cleveland Clinic has designated the Ombudsman
Ofice as the mechanism for addressing and resolving complaints or grievances.
The Cleveland Clinic will inform the patient that he/she has the right to file a grievance directly
to any of the following State Agencies: Ohio Department of Health at 1-800-669-3534; Ohio
KePRO's Medicare Beneficiary Helpline at
1-800-589-7337, or The Joint Commission, 1-800-
Oversight and Responsibility
A. The Grievance Committee is responsible for oversight and management of the Cleveland Clinic
Grievance Program, including educating the Cleveland Clinic staff and employees regarding the
B. The Ombudsman ofice implements the program and reports to the Grievance Committee.
Complaint: Any expression of dissatisfaction that can be resolved promptly or on the spot by staff
present. This can include concerns about the operations of providers such as: wait times, the demeanor
of health care personnel, the adequacy of facilities, and the respect paid to the patient
Grievance: Either a formal or informal verbal complaint that is made to the hospital by a patient or the
patient's legal guardian about an issue that cannot be resolved promptly by staff present, or a complaint
in writing. This includes any concen regarding the patient's care, abuse, or neglect issues related to the
hospital's compliance with the CMS Conditions of Participation and beneficiary complaints.
Patient's Rights & Patient's Responsibilities (flyers)
Ombudsman Contact Card (PWO 10462 10/06)
Ombudsman Brochure (102874 11/06)
Inpatient Admission Packet
CCTV Request Channel (Patient Education)
The Joint Commission Hospital Accreditation Standards APR.09.01.01 APR.09.02.01, RI.02.01.01